Hydroxyethyl starch (HES) adversely affect short-term survival and renal function of intensive care unit and possibly of surgical patients. We retrospectively investigated whether using HES as a pump prime and for intraoperative fluid therapy is associated with mortality and end-stage renal failure one year after adult cardiac surgery. Multivariable logistic regression was used to adjust for imbalanced characteristics between the two study groups. The primary outcome, a composite of end-stage renal failure or mortality during the first postoperative year was observed in 9.7% of patients who received HES and in 6.2% of patients treated with crystalloids only (Adjusted OR 1.05; 95%CI, 0.5-2; P = 0.9). These results suggest that using HES or balanced crystalloids as a pump prime and for intraoperative fluid therapy results in similar one-year outcomes but must be considered as preliminary given the limited statistical power of the study. [less ▲]

Hydroxyethyl Starches (HES) have been shown to increase the risk of acute kidney injury (AKI) in intensive care unit patients suffering sepsis. Whether this risk also applies to patients undergoing elective surgery remains unclear. We investigated whether HES is associated with acute kidney injury after on-pump cardiac surgery. Materials and Methods: Balanced HES 130/0.4 (Volulyte®, Fresenius Kabi AG, Bad Homburg, Germany) was used as a pump prime and for intraoperative fluid therapy until July 2013 and has been entirely replaced by a balanced crystalloid solution (Plasmalyte®, Baxter, Lessines, Belgium) from August 2013. Data from 697 adult patients undergoing cardiac surgery between April 2013 and June 2014 were reviewed. HES patients were propensity-matched on previously published risk factors for AKI after cardiac surgery to patients treated with crystalloids. Postoperative AKI was defined as the primary outcome and assessed using the Acute Kidney Injury Network classification. A conditional logistic regression was used to investigate the association between the use of HES and postoperative AKI. Secondary outcomes included renal function at postoperative day 7, 30-day mortality, lengths of ICU and hospital stays and the incidence of postoperative respiratory complications. Results and Discussion: One hundred and thirty HES patients were successfully matched with 130 crystalloids patients. HES was significantly associated with postoperative AKI (odds ratio=2.4; 95 % CI= 1.2-4.8; P=0.02). No significant association was found between HES and any of the secondary outcomes. Conclusion: This study suggests that using balanced HES 130/0.4 as a pump prime and for intraoperative fluid therapy in adult patients undergoing on-pump cardiac surgery is associated with a higher incidence of AKI during the early postoperative period. [less ▲]

With the emergence of rapid extubation protocols following cardiac surgery, providing adequate analgesia in the early postoperative period is important. This prospective randomised double-blind study ... [more ▼]

With the emergence of rapid extubation protocols following cardiac surgery, providing adequate analgesia in the early postoperative period is important. This prospective randomised double-blind study investigated the benefits of pre-operative intrathecal administration of low dose morphine in patients undergoing coronary artery bypass graft surgery. Postoperative analgesia, pulmonary function, stress response and postoperative recovery profile were assessed. Thirty patients were allocated into two groups, receiving either 500 mug of morphine intrathecally prior to anaesthesia and intravenous patient-controlled analgesia with morphine postoperatively following tracheal extubation, or only postoperative intravenous patient-controlled analgesia. In the intrathecal group, the total consumption of intravenous morphine following surgery was significantly reduced by 40% and patients reported lower pain scores at rest, during the first 24 h following extubation. Peak expiratory flow rate was greater and postoperative catecholamine release was significantly lower. Patients in the control group had a higher incidence of reduced respiratory rate following extubation. [less ▲]

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical ... [more ▼]

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture. [less ▲]

Anesthetic techniques and treatment of cardiac surgery patients have considerably evolved over the past twenty years. The demand for cardiac surgical procedures is increasing. This demand coincides with a ... [more ▼]

Anesthetic techniques and treatment of cardiac surgery patients have considerably evolved over the past twenty years. The demand for cardiac surgical procedures is increasing. This demand coincides with a change in the profile of patients presenting for surgery, requiring modification in perioperative management strategies. Several new anesthetics, related drugs, and technologies have become available in recent years that inevitably have made new approaches with patient management possible. In parallel to these new developments, there have appeared real opportunities to apply novel physiologic and pharmacologic concepts that may redefine our clinical practice. Fast-tracking, which emphasizes the major role of anesthetic management in postoperative outcome, is one such line of investigation. Fast-tracking was first introduced in an attempt to decrease the time to tracheal extubation and reduce expensive time in intensive care unit areas. Large doses of opioids have been clearly identified as a factor in delaying weaning from mechanical ventilatory support after cardiac surgery. Thus, early investigations emphasized the importance of limiting the dose of potent opioid analgesics during the intraoperative period to achieve early recovery. Supplementation with hypnotic drugs allows reduction of the opioid dose, enabling earlier extubation without compromising hemodynamic stability. Fast track cardiac anesthesia (FTCA) is becoming an accepted practice for perioperative management of cardiac surgical patients. FTCA is a key component to successful conduction of fast-track cardiac surgery. Also, analgesia management in cardiac surgery is becoming more important with the establishment of minimally invasive direct coronary artery bypass surgery and fast track management of conventional cardiac surgery patients. [less ▲]

This review of the recent literature regarding perioperative management in peripheral vascular surgery emphasizes some of the important features for the 2003 state-of-the-art on non surgical perioperative ... [more ▼]

This review of the recent literature regarding perioperative management in peripheral vascular surgery emphasizes some of the important features for the 2003 state-of-the-art on non surgical perioperative care for these high cardiac risk patients. The most adapted preoperative cardiac evaluation for each patient is guided by its individual risk factors and clinical history. Perioperative medication should nowadays consist of pre- and postoperative beta-blockers and acetyl salicylic acid, both reducing cardiac morbidity and mortality. Neuraxial locoregional anaesthesia techniques are reasonable alternatives to general anaesthesia because of their potential advantages, by reducing postoperative inflammatory response and reducing procoagulating activity, and increasing peripheral vascular graft patency, but the individual benefit/risk balance has always to be evaluated for patients submitted to aggressive antithrombotic therapy. During the postoperative course, early detection and treatment of postoperative myocardial ischemia or infarction by ST wave changes and/or cardiac enzyme control has to be considered. [less ▲]

OBJECTIVES: To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for ... [more ▼]

OBJECTIVES: To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice. DATA SOURCES: Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block. STUDY SELECTION: Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded. DATA EXTRACTION: Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia. DATA SYNTHESIS: 20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1. CONCLUSIONS: Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia. [less ▲]